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Screening for Asymptomatic Bacteriuria in Adults: US Preventive Clinical Review & Education JAMA | US Preventive Services Task Force | RECOMMENDATION STATEMENT Screening for Asymptomatic Bacteriuria in Adults US Preventive Services Task Force Recommendation Statement US Preventive Services Task Force Viewpoint page 1143 and IMPORTANCE Among the general adult population, women (across all ages) have the highest Editorial page 1152 prevalence of asymptomatic bacteriuria, although rates increase with age among both men Related article page 1195 and and women. Asymptomatic bacteriuria is present in an estimated 1% to 6% of JAMA Patient Page page 1222 premenopausal women and an estimated 2% to 10% of pregnant women and is associated Audio and Supplemental with pyelonephritis, one of the most common nonobstetric reasons for hospitalization in content pregnant women. Among pregnant persons, pyelonephritis is associated with perinatal complications including septicemia, respiratory distress, low birth weight, and spontaneous CME Quiz at jamanetwork.com/learning preterm birth. Related articles at OBJECTIVE To update its 2008 recommendation, the USPSTF commissioned a review of the jamanetworkopen.com evidence on potential benefits and harms of screening for and treatment of asymptomatic jamainternalmedicine.com bacteriuria in adults, including pregnant persons. POPULATION This recommendation applies to community-dwelling adults 18 years and older and pregnant persons of any age without signs and symptoms of a urinary tract infection. EVIDENCE ASSESSMENT Based on a review of the evidence, the USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in pregnant persons has moderate net benefit in reducing perinatal complications. There is adequate evidence that pyelonephritis in pregnancy is associated with negative maternal outcomes and that treatment of screen-detected asymptomatic bacteriuria can reduce the incidence of pyelonephritis in pregnant persons. The USPSTF found adequate evidence of harms associated with treatment of asymptomatic bacteriuria (including adverse effects of antibiotic treatment and changes in the microbiome) to be at least small in magnitude. The USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in nonpregnant adults has no net benefit. The known harms associated with treatment include adverse effects of antibiotic use and changes to the microbiome. Based on these known harms, the USPSTF determined the overall harms to be at least small in this group. RECOMMENDATIONS The USPSTF recommends screening pregnant persons for asymptomatic bacteriuria using urine culture. (B recommendation) The USPSTF recommends against screening for asymptomatic bacteriuria in nonpregnant adults. (D recommendation) Corresponding Author: Douglas K. Owens, MD, MS, Stanford University, 616 Serra St, Encina Hall, Room C336, JAMA. 2019;322(12):1188-1194. doi:10.1001/jama.2019.13069 Stanford, CA 94305-6019 Corrected on October 11, 2019. ([email protected]). 1188 (Reprinted) jama.com © 2019 American Medical Association. All rights reserved. USPSTF Recommendation: Screening for Asymptomatic Bacteriuria in Adults US Preventive Services Task Force Clinical Review & Education Summary of Recommendations The USPSTF recommends screening for asymptomatic B recommendation bacteriuria using urine culture in pregnant persons. The USPSTF recommends against screening for asymptomatic D recommendation bacteriuria in nonpregnant adults. See the Figure for a more detailed summary of the recommendation for clinicians. Asymptomatic bacteriuria is defined as the presence of bacteria moderate net benefit in reducing perinatal complications (Figure in the urine of a person without signs or symptoms of a urinary and Table; see the eFigure in the Supplement for explanation of tract infection.1 Among the general adult population, women USPSTF grades and levels of evidence). There is adequate evi- (across all ages) have the highest prevalence of asymptomatic dence that pyelonephritis in pregnancy is associated with negative bacteriuria, although rates increase with age among both men maternal outcomes and that treatment of screen-detected asymp- and women.2 The reported prevalence of asymptomatic bacteri- tomatic bacteriuria can reduce the incidence of pyelonephritis in uria ranges from 1% to 6% among premenopausal women to 22% pregnant persons. However, evidence shows that the incidence of among women older than 90 years.3,4 Asymptomatic bacteriuria pyelonephritis among pregnant women with untreated asymptom- is present in an estimated 2% to 10% of pregnant women.5 The atic bacteriuria has been low in recent decades, which may reduce condition is rare in men.4,6 thepotentialbenefitfromscreeningasymptomaticbacteriuria.When During pregnancy, physiologic changes that affect the urinary direct evidence is limited, absent, or restricted to select popula- tract increase the risk of asymptomatic bacteriuria and sympto- tions or clinical scenarios, the USPSTF may place conceptual upper maticurinarytractinfections,includingpyelonephritis(aurinarytract or lower bounds on the magnitude of benefit or harms. Therefore, infection in which one or both kidneys become infected).7 Pyelo- the USPSTF bounds the benefits of screening for asymptomatic bac- nephritis is one of the most common nonobstetric reasons for hos- teriuria in pregnant persons as no greater than moderate. pitalization in pregnant women.8 Pyelonephritis is associated with The USPSTF found inadequate direct evidence on the harms of perinatal complications including septicemia, respiratory distress, screeningforasymptomaticbacteriuriainpregnantpersons,although low birth weight, and spontaneous preterm birth.9 these harms are thought to be no greater than small in magnitude. The presence of asymptomatic bacteriuria has not been shown TheUSPSTFfoundadequateevidenceofharmsassociatedwithtreat- to increase the risk of adverse health outcomes among nonpreg- ment of asymptomatic bacteriuria, including adverse effects of an- nant persons.6,10 tibiotic treatment. It also considered the potential effects of changes in the microbiome resulting from antibiotic use. Therefore, the USPSTF bounds the overall magnitude of harms of screening for USPSTF Assessment of Magnitude of Net Benefit asymptomatic bacteriuria in pregnant persons to be at least small. Pregnant Persons Nonpregnant Adults The USPSTF concluded with moderate certainty that screening for The USPSTF concludes with moderate certainty that screening for and treatment of asymptomatic bacteriuria in pregnant persons has and treatment of asymptomatic bacteriuria in nonpregnant adults Figure. Clinician Summary for Screening for Asymptomatic Bacteriuria in Adults September 2019 For pregnant persons: Grade B Screen persons who are pregnant for asymptomatic bacteriuria with a urine culture. What does the USPSTF recommend? For nonpregnant adults: Grade D Do not screen adults who are not pregnant for asymptomatic bacteriuria. This applies to adults 18 years and older and pregnant persons of any age without signs and symptoms of a urinary tract infection. To whom does this recommendation apply? It does not apply to persons who have chronic medical or urinary tract conditions or are hospitalized or living in institutions such as nursing homes. This recommendation is consistent with the 2008 USPSTF recommendation. The USPSTF continues to recommend screening What’s new? for pregnant persons and recommends against screening for nonpregnant adults. Screen. Screen pregnant persons for asymptomatic bacteriuria using a midstream, clean-catch urine culture at the first How to implement this prenatal visit or at 12 to 16 weeks of gestation, whichever is earlier. A urine culture showing >100 000 CFU/mL of a single recommendation? uropathogen or >10 000 CFU/mL if the pathogen is group B streptococcus indicates treatment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. CFU indicates colony-forming units; USPSTF, US Preventive Services Task Force. jama.com (Reprinted) JAMA September 24, 2019 Volume 322, Number 12 1189 © 2019 American Medical Association. All rights reserved. Clinical Review & Education US Preventive Services Task Force USPSTF Recommendation: Screening for Asymptomatic Bacteriuria in Adults Table. Summary of USPSTF Rationale Pregnant Persons Nonpregnant Adults Detection Urine culture is the established method for detecting asymptomatic bacteriuria. Benefits of • There is inadequate direct evidence that screening for asymptomatic bacteriuria • There is inadequate direct evidence that screening for screening and improves health outcomes. asymptomatic bacteriuria improves health outcomes. treatment • There is adequate evidence that treatment of screen-detected asymptomatic • There is adequate evidence that treatment of bacteriuria reduces the incidence of pyelonephritis, a serious condition in screen-detected asymptomatic bacteriuria has pregnancy. However, given the lower prevalence of pyelonephritis found in more no benefit. recent studies, the overall benefits can be bounded as no greater than moderate in magnitude. Harms of • There is inadequate direct evidence to determine the harms of screening though There is inadequate direct evidence to determine the screening and they can be bounded to be no greater than small in magnitude. harms of screening and treatment. However, based
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